Principles and Techniques of
Biopsy
Principles and Techniques of
Biopsy

It is important to develop a systematic
approach in evaluating a patient with a
lesion in the Oral and Maxillofacial
region.
These steps include :

A detailed health history
 A history of the specific lesion
 A clinical examination
 A radiographic examination
 Laboratory investigations
 Surgical specimens for histopathologic
evaluation
Health History
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An accurate health history may disclose predisposing
factors in the disease process or factors that affect the
patients management.
Up to 90% of systemic deseases can be discovered
through history taking.
The same can be true of oral lesions when one is
familiar with the natural progression of the more
common disease processes.
Medical conditions that
warrant special care include:

Congenital heart defects
 Coagulopathies
 Hypertension
 Poorly controlled diabetics
 Immunocompromised patients
History of the Lesion
Questions to Ask

Duration of the lesion
 Changes in size and rate of change
 Changes in the character of the lesion.
– Lump to ulcer, etc

Associated systemic symptoms:
– fever
– nausea
– anorexia
More Questions to Ask

Pain
 Abnormal sensations
 Anesthesia
 A feeling of swelling
 Bad taste or smell
 Dysphagia
 Swelling or tenderness of adjacent lymph
nodes
 Character of the pain if present
Historical Reasons for the
Lesions:

Trauma to the area
 Recent toothache
 Habits
Clinical Examination

The clinical examination should always
include when possible:
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Inspection
Palpation
Percussion
Auscultation
Clinical Evaluation

The anatomic location of the lesion/mass
 The physical character of the lesion/mass
 The size and shape of the lesion/mass
 Single vs. multiple lesions
 The surface of the lesion
 The color of the lesion
 The sharpness of the boundaries of the lesion
 The consistency of the lesion to palpation
 Presence of pulsation
 Lymph node examination
Radiographic Examination

The radiographic appearance may provide
clues that will help determine the nature of the
lesion.
 A radiolucency with sharp borders will often be
a cyst
 A ragged radiolucency will often be a more
aggressive lesion
 Radiopaque dyes and instruments can help
differentiate normal anatomy
Laboratory Investigation

Oral lesions may be manifestations of
systemic disease.
 If a systemic disease is suspected it should
be pursued.
These include:

Tumor of hyperparathyroidism
 Padgets disease
 Multiple myeloma
 Determination of serum calcium,
phosphorus, and alkaline phosphatase
and protein can be very useful in excluding
certain pathological processes.
Indications for Biopsy

Any lesion that persists for more than 2 weeks
with no apparent etiologic basis
 Any inflammatory lesion that does not respond
to local treatment after 10 to 14 days.
 Persistent hyperkeratotic changes in surface
tissues.
 Any persistent tumescence, either visible or
palpable beneath relatively normal tissue.
Indications for Biopsy

Inflammatory changes of unknown cause that
persist for long periods
 Lesion that interfere with local function
 Bone lesions not specifically identified by
clinical and radiographic findings
 Any lesion that has the characteristics of
malignancy
Characteristics of lesions that raise the
suspicion of malignancy.
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Erythroplasia- lesion is totally red or has a speckled red
appearance.
Ulceration- lesion is ulcerated or presents as an ulcer.
Duration- lesion has persisted for more than two weeks.
Growth rate- lesion exhibits rapid growth
Bleeding- lesion bleeds on gentle manipulation
Induration- lesion and surrounding tissue is firm to the
touch
Fixation- lesion feels attached to adjacent structures
What is a Biopsy?

Biopsy is the removal of tissue for the
purpose of diagnostic examination.
Types of Biopsy

Oral cytology
 Aspiration biopsy
 Incisional biopsy
 Excisional biopsy
 Needle biopsy
Oral Cytology

Developed as a diagnostic screening
procedure to monitor large tissue areas
for dysplastic changes.
 Most frequently used to screen for
uterine cervix malignancy
 May be helpful with monitoring
postradiation changes, herpes,
pemphigus.
The Disadvantage of oral cytological
procedures include:

Not very reliable with many false positives.
 Expertise in oral cytology is not widely
available
 The lesion is repeatedly scraped with a
moistened tongue depressor or spatula type
instrument. The cells obtained are smeared on
a glass slide and immediately fixed with a
fixative spray or solution.
Aspiration Biopsy

Aspiration biopsy is the use of a needle and syringe
to penetrate a lesion for aspiration if its contents.
 Indications:
– To determine the presents of fluid within a lesion
– To a certain the type of fluid within a lesion
– When exploration of an intraosseous lesion is
indicated
Aspiration

An 18 gauge needle on a 5 or 10 ml
syringe is inserted into the area under
investigation after anesthesia is obtained.
 The syringe is aspirated and the needle
redirected if necessary to find the fluid
cavity.
Incisional Biopsy

An incisional biopsy is a biopsy that
samples only a particular portion or
representative part of a lesion.
 If a lesion is large or has different
characteristics in various locations more
than one area may need to be sampled
Incisional Biopsy

Indications:
– Size limitations
– Hazardous location of the lesion
– Great suspicion of malignancy

Technique:
– Representative areas are biopsied in a wedge fashion.
– Margins should extend into normal tissue on the deep
surface.
– Necrotic tissue should be avoided.
– A narrow deep specimen is better than a broad shallow
one.
Excisional Biopsy
An excisional biposy implies the complete removal of
the lesion.
 Indications:
– Should be employed with small lesions. Less than 1cm
– The lesion on clinical exam appears benign.
– When complete excision with a margin of normal tissue is
possible without mutilation.
Excisional Biopsy

Technique:
– The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is excised
if benign.
Principles of Surgery
Anesthesia

Block anesthesia is preferred to
infiltration
 When blocks are not possible distant
infiltration may be used
 Never inject directly into the lesion
Tissue Stabilization

Digital stabilization
 Specialized retractors/forceps
 Retraction sutures
 Towel Clips
Hemostasis

Suction devices should be avoided
 Gauze compresses are usually adequate
 Gauze wrapped low volume suction may
be used if needed
Incisions
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Incisions should be made with a scalpel.
They should be converging
Should extend beyond the suspected depth of the lesion
They should parallel important structures
Margins should include 2 to 3mm of normal appearing
tissue if the lesion is thought to be benign.
5mm or more may be necessary with lesions that appear
malignant, vascular, pigmented, or have diffuse borders.
Handling of the Tissue
Specimen

Direct handling of the lesion will expose it
to crush injury resulting in alteration the
cellular architecture.
Specimen Care

The specimen should be immediately
placed in 10% formalin solution, and be
completely immersed.
Margins of the Biopsy

Margins of the tissue should be identified
to orient the pathologist. A silk suture is
often adequate. Illustrations are also
very helpful and should be included.
Surgical Closure

Primary closure of the wound is usually
possible
 Mucosal undermining may be necessary
 Elliptical incision on the hard palate or
attached gingiva may be left to heal by
secondary intention.
Biopsy Data Sheet

A biopsy data sheet should be completed
and the specimen immediately labeled.
All pertinent history and descriptions of
the lesion must be conveyed.
Intraosseous and Hard Tissue
Biopsy

Intraosseous lesions are most often the
result of problems associated with the
dentition.
Indications for Intraosseous
Biopsy

Any intraosseous lesion that fails to
respond to routine treatment of the
dentition.
 Any intraosseous lesion that appears
unrelated to the dentition.
Clinical Exam

Palpation of the area of the lesion with comparison
to the opposite side.
 Any radiolucent lesion should have an aspiration
biopsy performed prior to surgical exploration.
– Information from the aspiration will provide valuable
information about the lesion.
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Solid
Fluid Filled
Vascular
Without Contents
Principles of Surgery
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Mucperiosteal flaps should be designed to allow
adequate access for incisional/excisional biopsy.
Incisions should be over sound bone
Cortical perforation must be considered when
designing flaps
Flaps should be full thickness
Major neurovascular structures should be avoided
Principles of Surgery

Osseous windows should be submitted with the
specimen
 Osseous preformations can be enlarged to gain
access
 Avoid roots and neurovascular structures
 The tissue consistency and nature of the lesion will
determine the ease of removal
Principles of Surgery

Incisional biopsies only require removal of a
section of tissue
 Soft tissue overlying the lesion should be
reapproximated following thorough irrigation
of the operative site.
 The specimen should be handled as previously
described
Biopsy Results: What If ?
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They don’t corroborate your clinical impression
– Repeat the biopsy!!!
– Determine if the tissue was looked at by an Oral
Pathologist
– The results show malignancy
When To Refer For Biopsy
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When the health of the patient requires special management
that the dentist feel unprepared to handle
The size and surgical difficulty is beyond the level of skill
that the dentist feels he/she possesses
If the dentist is concerned about the possibility of
malignancy